To report a case of pseudo-polycoria from iris biopsy managed by a daily disposable prosthetic colored hydrogel lens.
A 55-year-old- Caucasian female presented with complaints of photophobia in her right eye, that was exacerbated when going from a dark to light environment. Her past ocular history included a diagnosis by another outside physician of presumed multifocal iris melanoma in the right eye, followed by an iris biopsy performed one month later. Upon presentation to our clinic two months later, best corrected visual acuity was 20/20- in the right eye and 20/25 in the left eye. Slit lamp exam of the right eye revealed iris abnormalities, full-thickness biopsy defects at 2, 3 and 6 o’clock and a 0.8 × 0.7mm area of iris hyperpigmentation at 8 o’clock (Fig A,B,C, and D). The patient was provided with three non-surgical options to manage her symptoms: a commercially available soft daily replacement printed prosthetic hydrogel lens, a commercially available soft monthly replacement silicone printed prosthetic hydrogel lens, or a custom soft yearly replacement prosthetic hydrogel lens with dark inlay. The soft daily printed prosthetic hydrogel lens was chosen because of its ease in hygiene regimen and did not limit peripheral vision as the yearly dark inlay lens would.
The patient now wears Alcon Dailies® Color, Base curvature 8.6, Diameter 13.8, color mystic green in the right eye and her symptoms of photophobia have been resolved (Figure F).
There are limited options to manage photophobia in patients with polycoria or pseudo-polycoria. Surgical intervention is dictated by how many quadrants of iris are involved and therefore how symptomatic a patient may be. A less invasive alternative to surgical intervention is the use of a contact lens. In this case, traditional hand painted or printed yearly or monthly replacement hydrogel contact lenses were not used. Instead, a daily disposable hydrogel was successfully fit, highlighting that there is often a simple solution to a seemingly complicated issue.
Polycoria can be described as more than one pupillary opening in the iris. True polycoria is extremely rare and is defined by an additional pupil surrounded by an intact sphincter muscle. Contrastly, pseudo-polycoria is characterized by a full thickness iris defect that lacks a surrounding sphincter muscle. Because these pupillary defects lack a sphincter, when the primary pupil dilates, the accessory defects undergo reflexive constriction.
The bulk of iris tumors can be diagnosed with clinical or historical criteria without the need for cytologic or pathologic verification. In the case that observation may be dangerous or a diagnosis cannot be solidified based on clinical information and historical signs, other methods of verification can be used. Biopsy technique is selected based on the tumor location, size, friability, feeder or intrinsic vessels, and the risk of potential scattering of tumor onto the iris surface or anterior chamber angle. Biopsy techniques include fine-needle aspiration biopsy, surgical iridectomy through a corneal or limbal incision, iridiocyclectomy, and transcorneal tumor biopsy.
We will discuss pseudo-polycoria, as a complication of iris biopsy, its greatest visual consequence; photophobia, and a non-surgical alternative for management.
A 55-year-old- Caucasian female presented with the chief complaint of photophobia in her right eye, that was exacerbated when going from a dark to light environment. Her past ocular history included a diagnosis of presumed diffuse multifocal iris/ciliary body melanoma in the right eye, followed by an inconclusive diagnostic iris biopsy performed one month later by another outside physician. Upon presentation to our clinic two months later, best corrected visual acuity was 20/20- in the right eye and 20/25 in the left eye. Intraocular pressure was 13 mmHg/15 mmHg.
Slit lamp exam of the right eye revealed iris abnormalities, full-thickness biopsy defects at 2, 3:30 and 6:30 o’clock and a 0.7 × 0.8mm area of iris hyperpigmentation at 8 o’clock ( Fig. 1 & 2 ). Ultrasound biomicroscopy revealed an iris lesion at 7o’clock measuring 0.7 × 0.8 × 1.3mm, negative for extraocular extension or spontaneous vascular pulsations and intraocular extension ( Figs. 3 and 4 ). At this point, there were no overt signs of definitive malignancy. Since the previous pathology results from the iris biopsy were deemed to be inconclusive for melanoma, the assumption of an atypical iris nevus prevailed as the working diagnosis.